Mental health in Norway: Actors, organization and knowledge

The report presents and discusses the Norwegian Mental Health field in three parts: The first part offers a diachronic overview over major developments in the field. The next part describes the structure, the prevailing knowledge and important actors, and the third part discusses some aspects of mental health policy developments that seem important for the relationship between knowledge and politics in the mental health field in Norway.

Policies and Service System in Norway

The development of psychiatric
and mental health services in Norway follows the general pattern of welfare state
dynamics, but with some peculiarities. Modernisation of national welfare policies
has up until recently, in general terms, primarily been the result of broad alliances
between political and professional actors. The health sector – by some authors
labelled “the Queen of the Welfare State” - incarnated the integration of political
ambitions and professional management. From its beginning, psychiatric services
have, for their part, been dominated by the medical profession and political
bodies were reluctant to challenge suggestions put forward by psychiatrists.
Thus, psychiatrists attained monopoly over what was regarded as relevant
knowledge, simultaneously administrating the mental health central
administration and dominating the local implementation of mental health policies
in the capacity of combined professional and administrative leaders in the mental
health hospitals.

Recent Changes

Since the beginning of 1990’s several reforms have changed policies regarding
target groups, the formal structure of service organisations, scientific approaches
to mental health work, and the relations between professional actors and
governmental bodies at different levels. These changes are reflections of the
general trends towards new governance systems in the European welfare states,
but also some distinctive developments within the mental health field in the
country. Three developments have particular implications for the structuring of
general (municipal) and specialised (hospital) services. These developments are
embedded in reforms at the municipal level (the new Municipal Act of 1992) and
in specialised services (the hospital reform of 2002), and the Mental Health
Action Plan of 1998 – 2009. These reforms have had a great impact upon the
way structure, actors and knowledge intertwine in present mental health field
developments.

Discussion

Norwegian mental health service provision has, in accordance with European
trends, changed through three major developments: from an “era of the
asylum”, via the rise of mental health hospital systems to present-day vertical
and horizontal extension of mental health care. The Mental Health Action Plan
1998 – 2008 has played a major role in developments in the last phase. Mental
health service provision now see a substantial extension in policy ambitions and
services, which makes new (evidence- and practice-based) knowledge and issues
related to collaboration and coordination of services focal points in the
implementation of the Action Plan.

The mental health reforms (The Action Plan) and the administrative reforms
(municipal and hospital) were initiated in the 1990’s, and have changed the
design of service provision substantially. Three major developments can be
identified:

Firstly, the mental health field has seen a growth in economic resources, number
of patients, mental health professionals, and service agencies. The evaluations of
the Action plan conclude that the quantitative targets of the reform have been
fulfilled.

Secondly, there is agreement that the qualitative aspects of the reforms have not
been reached. This relates partly to the problems of coordination of service
provision. Here, the lack of coordination at the state level in the design of the
reform initiatives would be one important explanation: For specialised services,
the hospital reform did not refer to the Action plan, and vice versa. While the
Action Plan was designed according to “traditional” welfare reform
implementation tools, the hospital reform was a comprehensive New Public
Management reform. For general – municipal – services - the idea of the “new
municipality”, and the “governance” - partnership model of state – local relations
led to a complex web of semi-autonomous municipal decisions about the
organisation of municipal mental health services on the one side, and state audit
systems on the other. State governance about how to organise specialised and
general services, increasingly has been performed by state guidelines, but in
close collaboration with local actors.

Thirdly, there is agreement in the evaluations and among national political
decision makers that the users’ perspective has not been sufficiently elaborated
in service provision. This arguments should, however, be modified: while
empowering users through legal rights of individual patients are strengthened by
a new Law on Patients’ Rights, there still is a problem to make patients having
influence upon their treatment therapies and social roles in everyday life. As we
see it, two developments are particularly interesting for the understanding of the
relationship between knowledge and politics in the Norwegian mental health
field. First is the formal restructuring of services. The policy of formal
restructuring/decentralization of service provision includes two interconnected
issues: an emphasis upon organizing general/municipal services and a
regionalization (i.e. decentralization) of specialized/hospital services (District
Psychiatric Centers - DPS).

While the implementation of the restructuring has been subject to substantial
evaluation research, the genealogy of the knowledge processes - particularly
about the relationship between bio-medical/psychiatric knowledge and sociopsychological/
sociological scientific knowledge, and learning from international
developments - has not been subject to analysis yet. The restructuring /
decentralization seems to be informed mainly by two kinds of knowledge:
scientific approaches, in which the way bio-medical, sociological and
psychological understanding of mental health are represented and balanced, and
administrative approaches, in which cost-efficiency in service provision both in hospital reforms and in municipal service provision are represented. Likewise, the
interplay between (different) scientific knowledge(s) about mental health
problems and treatment strategies on the one side and administrative
approaches on the other, in processes of restructuring services should be
scrutinized.

We argue that within the KnowandPol project research questions should
concentrate on 1) where and by whom knowledge production takes place, how
knowledge producers advocating decentralization where given priority in the
formulation of mental health reform policies, and how “decentralization” was
operationalised. Different types of knowledge are mobilised in the restructuring
process, both regarding the extent of decentralization, and the design of service
provision organizations (tasks, size, management, recruitment/competencies).
Knowledge and actors should be seen to interplay in complex ways that need to
be analysed through case studies. We suggest some tentative hypotheses about
the relationship between knowledge and actors: The distribution of knowledge /
actors follow a pattern in which bio-medical knowledge is represented in
psychiatric hospitals, and tend to defend existing structures by the mobilization
of evidence-based medicine, while the actors advocating a restructuring /
decentralization are represented in DPSs and municipalities, on the basis of
sociological approaches to mental health problems.

2) The emphasis on user/citizen involvement, and the policies of empowerment
should be further analysed. The policy of user/citizen involvement represents as
we see it a “paradigm shift” – as the Action Plan has formulated the need for
increased influence of users/citizen perspectives on service provision. One
important aspect of this policy is the separation of professional/specialized
knowledge and the user/citizen perspectives or knowledge. This contrasts the
historical development of welfare state policies, in which professional knowledge
was said to include “user/citizen perspectives” as well. Here, one should ask
where and by whom the knowledge production takes place, what is meant by
“user/citizen involvement” in policy formulations, how this policy influence the
relations of power between professionals and users, and how this policy has been
included as a specific, central goal of the reforms.